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Family Violence SchemeApplication form Section 10M of the Fines Reform Act 2014

What is the family violence scheme?

Fines Victoria’s family violence scheme helps victim survivors with fines if there is a link between the family violence and their fines.

The scheme allows your infringement fine(s) to be withdrawn if:

• you are a victim of family violence, and• the family violence was one of the main reasons why you were unable to:

¾ control the conduct for which you received the fine, or

¾ name the driver that committed the offence.

What fines cannot be included in my application?

Although the scheme covers most fines, there are some that cannot be included in your application:

You cannot include a fine in your application if it was:

• issued by a court• issued to a company• for an offence against local council laws (except parking

fines)• for drink/ drug driving or drink/ drug boating• for excessive speeding (more than 25km/h over the limit

or over 130km/h).

You are unable to apply for the family violence scheme if:

• you have paid the fine in full• the fine has been referred to court• you have received a seven-day notice that has expired or

you waived the seven-day period• a Sheriff’s officer has seized your vehicle• the Director, Fines Victoria has:

• made an attachment of earnings or debt direction• recorded a charge over land that you own.

How do I apply?

The easiest way to apply is by accessing the application form at fines.vic.gov.au/fvs

You can submit the form and supporting evidence by:

In personFines VictoriaGround Floor, 277 William Street Melbourne, VictoriaOpening hours: 9am to 5pm Monday to Friday (except public holidays)

Fines Victoriafvs@justice.vic.gov.au

Email By postFines VictoriaPO Box 14487 Melbourne Victoria 8001

You can authorise a person to apply for the family violence scheme for you - such as a lawyer, guardian, financial counsellor, friend, or a family member.

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What do I need to include in my application?

Your application must:

• be in writing• provide your current postal address• list the fines you want included• explain why you think you are eligible

You should attach at least one item of supporting evidence. This can be either:

A document from a relevant authority or professional, such as:

• a family violence intervention order• a family violence safety notice• a report, letter or statement from a relevant

professional (for example, a lawyer, financial counsellor, social worker or psychologist)

See: A Guide to the Family Violence Scheme for more detail on what this evidence should cover.

A statutory declaration by you (if you cannot get a document from an authority or professional)

• Your statutory declaration needs to explain how you meet the eligibility criteria – especially the link between your experience of family violence and your fines.

• Your statutory declaration needs to be signed and witnessed by an authorised person. Visit justice.vic.gov.au/statdecs for a statutory declaration template and a list of people who can witness it for you.

Together, your application and the attached document(s) need to show how your experience of family violence was one of the main reasons for you being unable to control your actions or to make or reject a nomination.

We only need information that is directly relevant to you getting the fines. You do not need to provide lots of details of your relationship with the perpetrator, or all instances of family violence you have experienced.

Your application form does not need to repeat information that is included in a supporting document.

If we need more information to determine your application, we will ask you for it. If you cannot provide it by the due date, you can ask us for more time.

What happens after I apply?

Once we receive your application, we put your fines on hold. Once a decision is made, we will send you the outcome in writing.

If you are eligible for the family violence scheme, your fines will be:

• withdrawn (no further action will be taken against you, and any demerit points will be withdrawn), or

• put on hold so you can nominate the responsible driver within six months, if this is what you request. You should seek legal advice before choosing this option.

If you are not eligible for the scheme, you will have 21 days to take action to deal with your fines.

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How will you handle my information?

We will not share your information with the perpetrator of the family violence.

We collect personal information for the purposes of dealing with and enforcing your outstanding fine(s). We handle all applicants’ information confidentially and in accordance with the Privacy and Data Protection Act 2014 and the Health Records Act 2001.

We are required to provide your name, contact details, and fine details to the enforcement agency that issued the fine(s) when we receive your application, and again when we make our decision.

If we are concerned there is a serious threat to your or someone else’s life, health, safety, or welfare, we may disclose your information to police or child protection for protection purposes. We will attempt to get your consent first and will let you know if we have disclosed your information for this purpose.

Where can I get more guidance?

For more detailed information about the family violence scheme, you can access A Guide to the Family Violence Scheme.

To speak to a member of Fines Victoria’s specialist family violence scheme team call 1300 019 983 between 9am to 5pm Monday to Friday (except public holidays) or email fvs@justice.vic.gov.au

For information about family violence support services visit services.dffh.vic.gov.au/family-violence

For legal assistance, contact:

Victoria Legal Aid | legalaid.vic.gov.au | 1300 792 387

Federation of Community Legal Centres | fclc.org.au

Victorian Aboriginal Legal Service | vals.org.au

Justice Connect | justiceconnect.org.au

YouthLaw | youthlaw.asn.au

For assistance with managing your finances, contact:

Financial Counselling Victoria | fcvic.org.au/find-a-financial-counsellor/

National Debt Helpline | ndh.org.au/debt-problems/fines/ | 1800 007 007 (a free hotline)

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FAMILY VIOLENCE SCHEME APPLICATION FORM

Your details (the person affected by family violence)

I am the person affected by family violenceX

I would prefer not to provide my residential addressXI don’t have a fixed addressX

I am the affected person’s authorised representative, lawyer, or advocateX

Same as my residential addressX Another postal address (this could be a PO Box or address of a friend, or your authorised representative)X

NoX

Through my authorised person (please fill in details on the next page)X

I do not have a safe postal address, please email me (fill in the next section).X

Who is submitting the application?

I don’t have a driver licenceX

I have an international driver licenceXDriver licence number/Permit number State of issue

Date of birth

D D / M M / Y Y Y Y

Given name(s) Family name

Yes, to this addressX

Postal address

Suburb State Postcode Country(if not Australia)

1. Details

2. Postal address

3. Email contact

Use this form to apply for a review of your infringement fine(s) under the family violence scheme.

Section 10M of the Fines Reform Act 2014

We need to send you some information by post regarding your application. Please indicate your safest address for receiving correspondence.

Is it safe to email you about your application?

Residential address

Suburb State Postcode Country(if not Australia)

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Authorised person’s details

If yes, what are the safest days and times to call?

4. Telephone contact

Is it safe to call you to discuss your application?

If you are submitting this application on behalf of the person affected by family violence, complete this section. If you are the affected person and applying for yourself, leave this section blank.

Do you need an interpreter to assist you if we call you?

Relationship to person affected by family violence (if applicable)

Given name(s) Family name

Contact number Email address

Organisation or company name (if applicable) Position in organisation or company (if applicable)

NoXYes, on this numberX

NoXYes, which language?X

Can we leave a phone message at this number? Yes NoX X

How would you prefer to receive correspondence? Email PostX X

Can we call you regarding this application? Yes NoX X

Postal address

Suburb State Postcode Country(if not Australia)

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Your risk and support details (the person affected by family violence)

Your background and identity (the person affected by family violence)

What is the main language spoken at home?

These questions are optional. Any answers you provide will assist with de-identified statistical reporting and potential risk identification.

Do you identify as LGBTIQ? Yes NoX X

Are you or your children currently feeling afraid of a family member or experiencing family violence?

Yes NoX X

Would you like Fines Victoria to contact you to provide information about specialist family violence support services such as Safe Steps, 1800 Respect and Orange Door?

Yes NoX X

Has a support agency completed a risk assessment and a safety plan with you? YesX NoX I don’t

knowX

What is your gender? Female MaleX X Self-described (please specify)X

Do you have a disability or impairment?

Yes, please specifyX NoX

Do you identify as Aboriginal or Torres Strait Islander?

AboriginalX Torres Strait IslanderX Aboriginal and

Torres Strait Islander

X NoX

How well can you communicate in English?

Not at allX PoorlyX AdequatelyX Very wellX

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If you have listed fines above that are still at infringement stage (that is, you have not received a notice of final demand from Fines Victoria), please also include the details below:

Infringement number Enforcement agency Alleged offence Date and time of offence

Which fines do you want to include in the application?

Please select one of the options below.

Complete the table below only if you select option B or C. If there is not enough space, include an attachment.

X Option B Only the obligations listed in the table below.

X Option C All my outstanding obligations, except those listed in the table below.

Outcome you are seeking

Obligation or infringement number I would like the fine withdrawn

I would like to nominate the driver later

X Option A All my outstanding obligations. What outcome are you seeking for all your fines:

X I want them to be withdrawn (cancelled)

X I want to nominate the driver later (within six months)

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Nominating a driver

Reasons for application

If you are found to be eligible, you can nominate a driver within six months of receiving the outcome of your application – if you feel safe to do so. You can provide their details below now if you wish but we will always contact you before processing a nomination as we understand your situation may change.

Use this section to explain why you think you are eligible for the family violence scheme. We understand that providing this information can be distressing.

We need enough information to work out if you are eligible for the family violence scheme. We need to understand the link between the family violence and how it is relevant to you getting the fines.

You can leave this section blank if this information is included in the attached evidence (a document from a relevant authority or professional, or a statutory declaration).

Briefly describe how being a victim of family violence substantially contributed to you being unable to:

• control the conduct for which you received the fine, or • make or reject a nomination.

They don’t have a current driver licenceX

They have an international driver licenceXDriver licence number/Permit number State of issue

Date of birth (if known)

D D / M M / Y Y Y Y

Given name(s) Family name

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Signature of applicant Date

D D / M M / Y Y Y Y

Signature of authorised person or representative Date

D D / M M / Y Y Y Y

Checklist

Applicant declaration

Authorised person declaration (if applicable)

Submit your application

I have completed all the required fieldsX I have attached my supporting evidenceX

• I authorise Fines Victoria to disclose my personal information to the enforcement agencies that issuedthe fine(s), the Magistrates’ Court of Victoria and any person whose evidence I rely on in support of thisapplication, and

• The information supplied in this form is true and correct to the best of my knowledge, and

• I understand that by making a false or misleading statement in support of this application, I may beprosecuted.

• I have informed the applicant that their personal information may be disclosed to the enforcement agenciesthat issued the fine(s), the Magistrates’ Court of Victoria and any person whose evidence the applicant relieson in support of this application, and

• The information supplied on this form is true and correct to the best of my knowledge, and

• I understand that by making a false or misleading statement in support of this application, I may beprosecuted.

The applicant has consented to me making this application on their behalf. Yes NoX X

In personFines VictoriaGround Floor, 277 William Street Melbourne, VictoriaOpening hours: 9am to 5pm Monday to Friday (except public holidays)

Fines Victoriafvs@justice.vic.gov.au

Email By postFines VictoriaPO Box 14487 Melbourne Victoria 8001

Payment arrangements

Please note: If any of your fines are on a payment plan with an enforcement agency, you should contact them directly to cancel the plan. If you pay the fine in full, we cannot consider it in your application.

Do you have a payment arrangement with Fines Victoria for any of the fines in this application?

Yes NoX X

If yes, please note that if you pay your fines in full they will no longer be eligible for the scheme. Would you like us to remove the relevant fines from your payment arrangement while we consider your application?

Yes NoX X

If your application is not successful, would you like us to propose a new payment arrangement to include these fines again?

Yes NoX X